Periodontal diseases are infections that occur in the gums and bones that anchor the teeth. They are more likely to occur in people with diabetes than in nondiabetics, mostly as a result of poor glucose (blood sugar) control. Periodontal diseases can lead to pain, chewing problems and bleeding. In severe cases, gum tissue and supporting bone can be destroyed, resulting in tooth loss.
Dental health is especially important for diabetic individuals because scientists have linked periodontal problems to cardiovascular disorders. Cardiovascular problems, such as heart attack and stroke, are the leading cause of death for people with diabetes.
People with diabetes can reduce the risk of periodontal disease by managing their glucose. Diabetic patients who keep glucose under control are at no greater risk of periodontal diseases than others in the general population. Optimal glucose levels can also help people with diabetes to lower the risk of other health disorders, such as eye diseases, heart conditions and nerve damage.
Diabetic patients often find that dental infections make it more difficult to keep diabetes well-controlled. They can dramatically reduce the risk of periodontal disease by brushing and flossing regularly and scheduling dental cleanings at least every six months.
About dental care and diabetes
Periodontal diseases are infections that affect the soft gum tissues of the mouth and the bones that support and anchor the teeth in place. People with diabetes are more susceptible to these oral disorders if they have poorly controlled blood glucose (blood sugar).
In healthy teeth, gum tissue (gingiva) surrounds the neck of the teeth and leaves a shallow crevice. It is normal for bacteria from food particles, tissues and saliva to get into gingival crevices. When cleaning does not remove these substances, they form plaque, the main cause of periodontal disease.
Diabetes can promote periodontal diseases in several ways:
- Excess glucose in bodily fluids such as saliva provides a breeding ground for bacteria and increase buildup of plaque.
- Thickening of blood vessel walls is a common effect of diabetes. This can hinder blood from bringing oxygen and nutrients to body tissues and removing waste products created by the cells.
- High blood glucose (hyperglycemia) makes patients more susceptible to infections. Poor blood supply, another common diabetic complication, can leave the periodontal tissues too weak to fight infections. In addition, hyperglycemia can hinder the body’s ability to heal infections. Infections that are untreated or that linger can cause damage that becomes progressively worse. Pain, bleeding, difficulty chewing and tooth loss are some of the symptoms that can develop.
- The gum tissues may lose collagen. Collagen is a protein that supports the gums, skin, tendons, cartilage and bone. People with diabetes often lose collagen in the gum tissue, which hastens periodontal destruction.
Almost one-third of people with diabetes have severe periodontal diseases, according to the American Diabetes Association (ADA). This is defined as loss of attachment of the gums to the teeth that measures at least 5 millimeters. Even gestational diabetes, a temporary condition that can affect any woman during pregnancy, dramatically increases the risk of periodontal disease, and periodontal disease can aggravate prediabetes, according to recent research.
Periodontal disease begins with gingivitis, an infection of the gums. This occurs when plaque (a combination of bacteria, food and saliva, not to be confused with vascular plaque of atherosclerosis) settles at the gum line, builds up and begins to attack the tissues. The gums become swollen and may bleed when the patient brushes or flosses. Regular brushing, flossing and dental cleanings can clear away plaque and help reverse gingivitis.
Left untreated, gingivitis can lead to another gum disease called periodontitis. This is a more serious infection of the soft tissues and bone that anchor the teeth in place. Plaque builds and hardens and sinks under the gums, which pull away from the teeth and open pockets of infection. Germs and pus fill these pockets, which then deepen. As the gum tissues recede, teeth loosen. Surgery is often necessary at this point to save the teeth.
Without treatment, periodontitis will progress and eventually cause a loss of the bone that holds the tooth in its socket. The tooth may become loose and start to move before falling out. However, treatment of periodontal disease may help control diabetes by decreasing oxidative stress (increasing levels of antioxidants), according to recent research.
Other dental conditions associated with diabetes include:
- Oral thrush (oropharyngeal candidiasis). An infection caused by a fungus that grows in the mouth and that feeds on high levels of glucose in saliva. Thrush creates white (or sometimes red) patches in the mouth that become sore and can turn into ulcers. It occurs in moist spots that are chafed or sore, such as under dentures that do not fit well. Smoking can trigger this fungal infection, which can be treated with medication.
- Dry mouth (xerostomia). Frequently a symptom of undetected diabetes that results from poor control of glucose. Saliva helps curb the growth of germs, washes away sticky foods that form plaque and strengthens teeth with minerals. Dry mouth can cause soreness, ulcers, infections and tooth decay.
While diabetes raises the risk of periodontal disease, dental infections can in turn complicate management of diabetes. Periodontal disease can affect diabetes by:
- Triggering several conditions that hinder a patient’s ability to control blood glucose. These include hyperglycemia, mobilization of fatty acids and acidosis (abnormal increase in acidity in body fluids).
- Preventing proper nutrition when sore gums or loose teeth make chewing difficult. As a result, these patients may choose softer foods that may also be dietetically inappropriate.
Numerous research studies have linked dental health to cardiovascular health and periodontal disease to disorders of the heart and blood vessels. These findings are especially significant for diabetic individuals because cardiovascular conditions, such as heart attack and stroke, are the leading cause of death for people with diabetes. Scientists from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) have also found diabetic periodontal disease to be a strong predictor of fatal kidney disease as well as fatal heart disease. Other research has linked periodontal disease to complications including increased risk of rheumatoid arthritis and premature labor.
Risk factors and potential causes of periodontal disease
In most cases, periodontal diseases in people with diabetes are the result of poor glucose (blood sugar) control. Those with chronically elevated glucose (hyperglycemia) tend to suffer infections that are more frequent and more severe. They also are more likely to lose teeth than those who control their glucose.
It appears that poorly controlled glucose contributes to:
- Unhealthy levels of cholesterol and other lipids, particularly elevated serum triglycerides. These appear to contribute to greater attachment loss and probing depths, which are measures of periodontal disease.
- Elevated levels of cytokines in gingival tissue. High levels of these proteins (involved in immune system response) can cause destructive inflammation of the gums.
- Lower levels of growth factors. The lack of these beneficial proteins interferes with the healing response to infection.
Other factors related to diabetes that raise the risk of periodontal disease include:
- Poor maintenance of the teeth. Lack of proper brushing and flossing promotes the formation of dental plaque, a sticky bacteria film that builds up on teeth. Such germs cause gum disease.
- Bacteria. Germs that are harmful to teeth thrive on sugars, including glucose. High levels of glucose in mouth fluids are a breeding ground for bacteria and set the stage for gum disease.
- Thickening of blood vessels. Blood vessels bring oxygen and nourishment to tissues throughout the body and carry away waste products. Diabetes often damages these vessels, causing them to thicken. This hampers the flow of nutrients to tissues and the removal of wastes, increasing the susceptibility of gum and bone tissue to infection.
- Smoking. People who smoke are five times more likely than nonsmokers to have gum disease, and the risk for diabetes patients is even greater. Diabetic smokers age 45 or older are 20 times more likely than a person without these risk factors to get severe gum disease.
Signs and symptoms of periodontal disease
The first symptoms of gingivitis include bleeding during brushing and flossing. Early indications of the more advanced periodontitis are not always obvious. However, in advanced stages pain, abscess and loosening of the teeth may occur.
Other symptoms of periodontal disease include:
- Red, sore, swollen gums
- Gums that pull away from the teeth, making the teeth appear long
- Loose or sensitive teeth
- Bad breath
- Bite that feels different
- Dentures that no longer fit well
- Teeth that are loose or moving away from each other
- Pain when chewing
- Sensitivity of teeth to hot, cold and sweets
- Dark spots or holes in the teeth
Diagnosis and treatment of dental disease
In checking for periodontal disease, a dental professional will measure the spaces between the gums and the teeth with a periodontal probe. This is a small instrument that resembles a ruler.
X-rays of the mouth are also likely. This will help reveal the extent of damage to the supporting bone around the teeth and gums. Researchers have found that dental x-rays may in some cases also reveal early warning signs of carotid artery disease and stroke, and osteoporosis.
People with diabetes should be checked for periodontal disease at least every six months. Many dentists schedule diabetic patients more often, such as every three months. Children with type 1 diabetes are particularly vulnerable to early-onset periodontal disease as they reach adolescence.
Treatments for periodontal disease range from at-home care to surgery, depending on the nature of the infection. Early-stage disease (gingivitis) can usually be reversed through good maintenance. Regular brushing and flossing, and visits to a dental professional at least twice yearly, can help prevent this infection.
Periodontitis cannot be treated or reversed with simple brushing and flossing. People with the condition should see a periodontist (specialists in gum disease) or general dentist for treatment.
Bacteria that form in the spaces between the teeth and under the gum line are treated by using small dental scalers. This is called debridement, sometimes known as scaling or root planing. As part of this process, smooth surfaces are created on the damaged root surfaces of the teeth that help healing gum tissues to tighten around the teeth. Debridement is often completed over a series of visits.
Antibiotics and antibacterial mouth rinses are also often prescribed.
In severe cases of periodontitis, gum surgery may be needed to reshape or replace tissues. The types of surgery include:
- Crown lengthening, which removes gum tissue and sometimes bone to expose more of the tooth
- Gingival flap surgery, which temporarily separates the gums from teeth so the practitioner has access to dental roots and bone for removal of inflamed tissue, plague and tartar
- Gingivectomy, which removes gum tissue to eliminate pockets or reduce excess gum tissue around teeth
- Soft-tissue graft, which removes tissue from the palate or another area and adds it to an area where gums have receded
- Bone surgery or grafting, which replaces, rebuilds or reshapes the bone that supports teeth.
Patients who have been treated for periodontal disease must regularly brush and floss, or the condition will return.
Prevention methods for periodontal disease
Patients with diabetes can drastically reduce the risk of periodontal disease through several preventive measures. A crucial step is controlling glucose (blood sugar). Several studies have shown that diabetic patients who maintain healthy levels of glucose are at no greater risk for periodontal disease than nondiabetics.
Other tips include:
- Brushing after every meal or snack with a soft-bristle brush to prevent buildup of plaque.
- Flossing deeply and thoroughly at least once daily to prevent buildup of plaque. Many people floss and brush incorrectly. A dental hygienist or dentist can offer instruction.
- Using a tongue scraper and toothbrush to clean the tongue, which often traps germs.
- Using a fluoride toothpaste to protect teeth from decay.
- Buying red “disclosing tablets” at a pharmacy. These stain plaque and allow patients to see where plaque is building up on the teeth.
- Having a dental checkup and teeth cleaning at least twice a year, or more often as recommended by their dentist or physician.
- Informing the dentist that a patient has diabetes. Elevated glucose (hyperglycemia) can hinder healing from minor tissue injuries that may occur during dental exams and procedures. When glucose is not controlled, patients should discuss with the dentist whether dental surgery should be rescheduled, because poorly controlled glucose will slow healing. Patients may wish to ask if the surgery should be done in a hospital where the patient can be closely monitored in case of emergencies.
- Keeping false teeth clean.
- Maintaining a nutritious diet and getting regular exercise. The habits can promote oral health as well as diabetic health. For example, recent research suggests that eating high-fiber whole grains may reduce risk of gum disease in addition to stabilizing levels of glucose.
- Not smoking. Tobacco use is a risk factor for dental disease and other complications including diabetic retinopathy, diabetic neuropathy, diabetic nephropathy and cardiovascular disease.
- Avoiding alcohol-based mouthwashes. These products promote dryness of the mouth.
- Replacing the toothbrush every three months. Bacteria grow on the bristles, and a new toothbrush will remove more plaque.
- Immediately taking care of any problems noted by a dentist.
- Treating dry mouth. Drinking enough water and chewing sugarless gum can keep the mouth moist.
- Getting enough sleep. Lack of sleep may worsen progression of periodontal disease, according to recent research.
For some patients, preventive care also includes use of antibiotics before dental procedures to avert heart infections such as bacterial endocarditis. These patients include those who have received a mechanical heart valve, or who have certain congenital or valvular heart diseases or myopathies (conditions involving enlargement of the heart).
In addition, patients may be advised by their physician or dentist to suspend use of aspirin for several days before dental procedures to reduce the risk of bleeding.
Questions for your doctor
Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor or dentist the following questions about dental care and diabetes:
- How does diabetes affect my need for dental care?
- How does diabetes affect my risk of gum and dental problems?
- How often should I receive dental care?
- What should my visit include?
- Do I need to take antibiotics before undergoing dental procedures, or suspend my use of aspirin or any other medications?
- Do I have any signs of gingivitis or periodontitis?
- Do my dental x-rays show any early evidence of carotid artery disease, stroke or osteoporosis?
- What treatments might I need?
- Do I need to see a periodontist or oral surgeon?
- Can my oral hygiene affect my risk of heart disease, kidney disease or other disorders?
- How can I prevent diabetic dental problems?
- Do I have to be more careful flossing because of my diabetes?